Pages

Thursday, September 5, 2013

I write this post after reading Margalit Gur-Arie's excellent post on Alternative Health IT. She's one of those people who when they write, I not only listen, but I make sure others know about her posts automatically via Twitter. It's a short list.

I'm a bit challenged by her post, because in many ways I agree, and in others, I disagree. What I find stifling is the pace at which Meaningful Use is proceeding. When you put an entire industry under the MU pressure cooker, the need to meet Federal Mandates overwhelms anything else. The need to develop software that is able to support a large number of externally controlled mandates can, and in many cases, has resulted in bad engineering. You can't innovate well on a deadline. It's not a well-understood repeatable process (actually it is repeatable, but few are able to define and execute on it, but that's for another post). What results is often "studying to the test", and neither developers nor end users never really learn the lessons that Meaningful Use is attempting to teach. I've seen multiple times where developers produce a capability that meets the requirements of the test, but which fails to meet the requirements of the customer. See John Moehrke's excellent analysis of what it takes to pass encryption tests in Stage 1. If you do JUST what it takes, you can wind up with something that customers don't need and won't use.

In some ways, the test itself is to blame. But in other ways, it is our attitudes on what that software is supposed to do that is to blame. Margalit makes several points about the utility of gathering family history and smoking status for patients for whom other things are more important. One of the first rules of care in the ED is to stabilize the patient. That means that other things (like capturing medical history) should wait. If your EHR forces you to a workflow that doesn't support that necessity in the ED, by all means, replace it. If your process requires the capture of data for every single patient that you don't always need , perhaps you should revise it. The metrics in meaningful use require that for patients admitted (in a hospital) or treated (in an ambulatory or ED setting); 80% have smoking status and 20% have family history recorded. This isn't an all or nothing measure. MU isn't saying do it every single time, but it is saying that this should be part of your practice for most or some patients. I agree the numbers might be usefully adjusted for different settings, but arguably it is also lot less costly and challenging (for the government) to set one measure for everybody. Is it fair to consider that X is too high a number? Possibly. Is there a number that would make everyone happy? Hell no. So we pick one and live with it, and move on. It's NOT quite as scary or as stupid as it might seem.

The test for providers is more challenging than the test for the developers. It is made of a couple of dozen questions, and each one is a pass fail question, and you have a year, or 90 days, or whatever, before you find out if you've passed (although you can monitor it). Failing on any single question results in failing the test overall. This would be like having a class in which you given 10 tests over the course of the semester, and you assign to the student at the end of the year the lowest grade of any single one of the tests. I think we'd be better off with a bunch of pass/fail questions and a set metric of what score is needed to pass overall (That's what the menu options do, but few actually see it that way because there often aren't enough of them to be relevant choices).

On where Meaningful Use is succeeding in developing innovation, I think there are a few places of note. Blue Button Plus supports unprecedented patient access, and while NOT directly required by name in Meaningful Use Stage 2, is built from readily accessible components and requirements that are present in Stage 2. I'm speaking specifically of the View, Download and Transmit requirements in the incentives rule, and on the standards side, Consolidated CDA [arguably a refinement of an innovation produced several years ago], and standards applied in the Direct Project. Stage 3 has much more to offer I think, even though we are just starting to get a handle on what it might look like. The Query Health initiative did some really innovative work that supports not just its particular use case (health research), but also automation of quality measurement using HL7's HQMF. If you think developing a declarative means for specifying quality measures (and using that for research as well) isn't innovative, you certainly haven't been viewing some of the challenges we were trying to solve from my perspective.

It's not all bad. It's not all good. But overall, I think the end result does not paint quite as depressing a picture. And it is just one program. It is the biggest one we have right now, but that's about to change. The ACO rule is kicking in, and we are starting to see providers (who now have an EHR due to meaningful use), start to look at real innovations that support better care. For them, there's only one test score (how much savings there is at the end of a term), but they get to define the curriculum and how it will be learned.

5 comments:

There is a lot of good that came with the MU program, along with some pretty bad stuff too. I think initially, it was worth it because MU did move adoption of technology beyond the tipping point, something that would have taken maybe a decade longer without it.

I have this mental image of ONC pushing the huge rock of technology to the top of the mountain, and now insisting on continuing to push it down to the other side. There is no need to do that anymore. Letting it roll down on its own is much easier and much faster. I think continuing this staged and paced march of regulatory software development is now doing more damage than good. It's time to let go and trust that we did a good job to position HIT to succeed (it's like raising kids I think :-). I am not arguing that ONC should just step aside and dismantle itself, but that it continues to develop the tools and standards that may be needed in the future, without trying to enforce any particulars about their use. If the stuff is good, it will be used.

As you mentioned towards the end, other things are happening simultaneously, and innovation is bound to explode in this market. Some will be good, other will be horrific. I think we should just let it sort itself out (from an IT perspective), because there is no way for us to determine which nuts and bolts will be pertinent to the eventual right solution. Besides, it is much more interesting to see what developers create without knowing three years in advance exactly how every piece of EHR software will look.

I guess, I am just growing impatient with the pace of progress and I know there are bunches of talented folks out there that have all sorts of crazy ideas, and I want to see those tried out, more than I want to see the federal government innovators decreeing that 30% of visits should have a visit note.

Yup, and I share your pain. If they left it all up to me, I'd do it differently, and faster, and probably wrong. I'm somewhat hopeful that Stage 3 will look a bit different. I like the idea that meeting certain quality goals is a better measure of meaningful use than our current method of evaluation.

MU's sense of urgency and push toward convergence is a Good Thing, in my opinion. We have too much of a Good Thing. I want ONC to embrace standards more than set them.

I have often said that standards are a measure of divergence from the norm, not just a set of rules to be strictly followed. They serve as a fixed point from which we can measure innovation. If all we do is follow the rules, we get no innovation. I want the rules to be broken purposely.

We need some metrics to help evaluate innovation. Perhaps that's ONC's best role. The metrics would establish long-term objectives and measure progress toward them. The key is to favor beneficial order over the entropy that comes from innovation for the mere sake of gaining market differentiation.

My preference is toward innovation that aids clinical workflow for caregivers and consumers. The metrics include better outcomes, higher availability, and lower systemic cost. I have a personal stake in this, as a Medicare recipient, seeking a measurably longer and more healthy retirement with a price that keeps pace with the Social Security COLA.

I work for an EHR company and assist physicians to meet MU/PQRS requirements every day. If practices were not forced into EHR adoption most wouldn't commit the time and expense. I understand their concerns. It's disruptive to their medical practice. I also agree with what you are saying Keith about "studying to the test". I see it in my own company as we are designing Stage 2 software. The only thing that gets attention is meeting the certification criteria. Innovation, better health care....yeah let me get back to you on that.

And I don't know a better way to do it. I am certainly unhappy with the amount of regulation that has swamped the medical industry in our country. I hope there is one day an environment where our processes and technology have moved us to a new level where we will really achieve a higher standard of healthcare that is really cost-effective.